ABSTRACT
During deep inferior epigastric artery perforator (DIEP) flap dissection, we noted that in many cases the superficial vein on the ipsilateral side of the flap was engorged and tense, and in others, it was empty. This led us to believe that the pressure is increased as the result of preferential outflow through the superficial vein in some cases, which could result in venous congestion of the flap if this vessel was not anastomosed. To test this hypothesis, we measured the venous pressure in the superficial venous system before and after flap dissection. The pressure in the superficial inferior epigastic vein of a DIEP flap was measured in 26 consecutive flaps to investigate the correlation between the pressure and venous congestion of the flap. The first measurement was performed at the beginning of the dissection, and the second measurement was taken after the flap had been completely raised on a single perforator. The mean increase in pressure after flap dissection was 10.6 mm Hg (μ = 10.6; range −1 to 31; Ó ± 7.0 mm Hg). Clinical signs of venous congestion were observed in one case. In this case, the increase in venous pressure was with 31 mm Hg, also the highest. Although the results of this report are preliminary, they indicate that the pressure in the superficial vein of DIEP flaps might be of predictive value for venous congestion.
KEYWORDS
Venous congestion - venous pressure - superficial inferior epigastric vein - microvascular breast reconstruction - deep inferior epigastric perforator flap
REFERENCES
1
Koshima I, Soeda S.
Inferior epigastric artery skin flaps without rectus abdominis muscle.
Br J Plast Surg.
1989;
42
645-648
2
Garvey P B, Buchel E W, Pockaj B A et al..
DIEP and pedicled TRAM flaps: a comparison of outcomes.
Plast Reconstr Surg.
2006;
117
1711-1719
discussion 1720-1721
3
Nahabedian M Y, Tsangaris T, Momen B.
Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?.
Plast Reconstr Surg.
2005;
115
436-444
discussion 445-446
4
Chen C M, Halvorson E G, Disa J J et al..
Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps.
Plast Reconstr Surg.
2007;
120
1477-1482
5
Futter C M, Webster M H, Hagen S, Mitchell S L.
A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap.
Br J Plast Surg.
2000;
53
578-583
6
Damen T H, Timman R, Kunst E H, Gopie J P, Bresser P J, Seynaeve C, Menke-Pluijmers M B, Mureau M A, Hofer S O, Tibben A.
High satisfaction rates in women after DIEP flap breast reconstruction.
J Plast Reconstr Aesthet Surg.
2008;
, November 24 (Epub ahead of print)
7
Smit J M, Dimopoulou A, Liss A G, Zeebregts C J, Kildal M, Whitaker I S, Magnusson A, Acosta R.
Preoperative CT angiography reduces surgery time in perforator flap reconstruction.
J Plast Reconstr Aesthet Surg.
2009;
62
1112-1117
8
Tran N V, Buchel E W, Convery P A.
Microvascular complications of DIEP flaps.
Plast Reconstr Surg.
2007;
119
1397-1405
discussion 1406-1408
9
Villafane O, Gahankari D, Webster M.
Superficial inferior epigastric vein (SIEV): “lifeboat” for DIEP/TRAM flaps.
Br J Plast Surg.
1999;
52
599
10
Blondeel P N, Arnstein M, Verstraete K et al..
Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps.
Plast Reconstr Surg.
2000;
106
1295-1299
11
Sloan G M, Reinisch J F.
Flap physiology and the prediction of flap viability.
Hand Clin.
1985;
1
609-619
12
Sloan G M, Sasaki G H.
Noninvasive monitoring of tissue viability.
Clin Plast Surg.
1985;
12
185-195
13
Chen K T, Mardini S, Chuang D C et al..
Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers.
Plast Reconstr Surg.
2007;
120
187-195
14
Smit J M, Acosta R, Zeebregts C J, Liss A G, Anniko M, Hartman E H.
Early reintervention of compromised free flaps improves success rate.
Microsurgery.
2007;
27
612-616
15
Jallali N, Ridha H, Butler P E.
Postoperative monitoring of free flaps in UK plastic surgery units.
Microsurgery.
2005;
25
469-472
16
Whitaker I S, Gulati V, Ross G L, Menon A, Ong T K.
Variations in the postoperative management of free tissue transfers to the head and neck in the United Kingdom.
Br J Oral Maxillofac Surg.
2007;
45
16-18
17
Liss A G, Liss P.
Use of a modified oxygen microelectrode and laser-Doppler flowmetry to monitor changes in oxygen tension and microcirculation in a flap.
Plast Reconstr Surg.
2000;
105
2072-2078
18
Repez A, Oroszy D, Arnez Z M.
Continuous postoperative monitoring of cutaneous free flaps using near infrared spectroscopy.
J Plast Reconstr Aesthet Surg.
2008;
61
71-77
19
Cai Z G, Zhang J, Zhang J G et al..
Evaluation of near infrared spectroscopy in monitoring postoperative regional tissue oxygen saturation for fibular flaps.
J Plast Reconstr Aesthet Surg.
2008;
61
289-296
20
Scheufler O, Exner K, Andresen R.
Investigation of TRAM flap oxygenation and perfusion by near-infrared reflection spectroscopy and color-coded duplex sonography.
Plast Reconstr Surg.
2004;
113
141-152
discussion 153-155
21
Holm C, Tegeler J, Mayr M, Becker A, Pfeiffer U J, Mühlbauer W.
Monitoring free flaps using laser-induced fluorescence of indocyanine green: a preliminary experience.
Microsurgery.
2002;
22
278-287
22
Hölzle F, Loeffelbein D J, Nolte D, Wolff K D.
Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry.
J Craniomaxillofac Surg.
2006;
34
25-33
23
Lundberg J, Mark H.
Avoidance of complications after the use of deep inferior epigastric perforator flaps for reconstruction of the breast.
Scand J Plast Reconstr Surg Hand Surg.
2006;
40
79-81
24
Schaverien M, Saint-Cyr M, Arbique G, Brown S A.
Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps.
Plast Reconstr Surg.
2008;
121
1909-1919
25
Ayhan S, Oktar S O, Tuncer S, Yucel C, Kandal S, Demirtas Y.
Correlation between vessel diameters of superficial and deep inferior epigastric systems: Doppler ultrasound assessment.
J Plast Reconstr Aesthet Surg.
2009;
62
1140-1147
Anders G LissM.D. Ph.D.
Department of Plastic and Reconstructive Surgery, Uppsala University Hospital
SE-751 85 Uppsala, Sweden
eMail: jermasmit@gmail.com
eMail: info@lissliss.se